The following email went out to all nurses today:

You are no doubt aware of the critical shortages of IV fluids and injectable narcotics. Our supply is VERY low and there is no definite end to the shortage in sight. As such, we must take bold steps to reduce our usage of each, or risk completely exhausting our supplies. Here are some steps that have been approved by HH Administration, P&T Committee, and Med Exec Committee:

IV fluids:

• Continue to give all drugs approved for IV push via this route - we could run out of all piggybacks, soon; we must save as many piggybacks as possible for drugs that require greater dilution
• Discontinue IVs running at < 45 mL/hr in patients who are taking PO meds and/or diet/fluid. You may AUTOMATICALLY discontinue these IVs after consulting with Pharmacy. If IV access is needed but the patient can meet their fluid needs orally, automatically convert to saline lock after consultation with Pharmacy.
• If the patient has NG-/G-tube feedings, automatically discontinue IV fluid (or convert to saline lock if access needed) after consultation with your pharmacist and provide adequate fluid via the tube.
• If a flowing IV is needed, automatically reduce all KVO regimens to 20 mL/hr
• You may notice a sudden substitution of one fluid or bag size for that which is ordered...we are managing many of these shortages day-to-day due to abrupt shifts in availability
• Feel free to contact the prescriber if you feel the need to obtain additional orders for fluids via the oral or tube route

Injectable narcotics (see Kristen Flanagan's email from 2/13/18):

• Automatically convert IV narcotics to PO in patients who are able to take PO meds/diet - pharmacists and nurses should work together to accomplish this conversion. If patient is a chronic pain or cancer patient, consult with MD before converting IV to PO
• If an IV/IM narcotic if stopped and the patient becomes unable to take PO, you may automatically resume the IV/IM narcotic order that you d/c'd
• If patient has an order for both IV/IM and PO narcotics, use PO whenever possible. Again, this is an automatic conversion after pharmacist/nurse collaboration.
• Pharmacists will convert regimens that waste narcotics to the next lower dose. Example, if morphine 1-5 mg is ordered, the 5 mg dose must be obtained from an 8 or 10 mg vial...wasting 3-5 mg. In this case, the pharmacist will automatically convert the regimen to 1-4 mg, resulting in less waste.
• Surgery/anesthesia will be adding multi-modal analgesia to pre- and post-op order sets.

Thanks for your help with the shortages thus far, and thanks in advance for helping us maintain our supplies as long as possible. Please review this information and act as needed. Also, do not hesitate to contact me if you have any questions.

Please give high priority to reviewing your profiles for IV fluids and narcotics that can be provided orally/enterally. As you can see, P&T and MEC have given us wide latitude to work with nurses to accomplish our goal of preserving our supplies as long as possible. With patient safety always in the forefront, err on the side of aggressiveness in moving from IV fluids and injectable narcotics to PO -- "PUSH P.O." is the catch phrase we are using and it is the best way to extend our supply!

DAVID
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David R. Collette, Pharm.D., FASHP
Operations Manager, Professional Services